A boy playing football develops sudden painful, non‑reducible groin swelling without cough impulse, fever, and markedly elevated white‑blood‑cell count; what is the appropriate management?

Surgical Exploration for Incarcerated Inguinal Hernia with Suspected Strangulation

This boy requires immediate surgical exploration (Option C) due to the clinical presentation of an incarcerated inguinal hernia with signs of strangulation—the combination of sudden-onset painful non-reducible groin swelling, fever, and markedly elevated WBC count (130,000) indicates bowel compromise requiring emergency intervention within 6 hours. 1

Critical Clinical Features Indicating Strangulation

The presentation contains multiple high-risk indicators for bowel strangulation:

• Non-reducible groin swelling with acute onset during physical activity suggests incarceration with potential progression to strangulation 1
• Fever and extreme leukocytosis (WBC 130,000) represent systemic inflammatory response syndrome (SIRS), which independently predicts strangulated bowel obstruction 2, 1
• Absence of cough impulse indicates the hernia contents are trapped and non-viable tissue may be present 3

The markedly elevated WBC count is particularly concerning—while elevated WBC is moderately predictive of strangulation, a count this extreme (130,000) suggests severe infection or tissue necrosis, potentially indicating Fournier's gangrene or advanced bowel strangulation 2, 1

Why Other Options Are Inappropriate

Option A (Aspiration) is contraindicated because:

• This is not a simple hematoma—the clinical picture with fever and extreme leukocytosis indicates infection or strangulated bowel 1
• Aspiration delays definitive surgical treatment, and each hour of delay increases mortality by 2.4% 1

Option B (Analgesics and observation for 8 hours) is dangerous because:

• Delayed treatment beyond 24 hours dramatically increases mortality rates 1
• Symptom duration >8 hours significantly increases morbidity and need for bowel resection 1
• The presence of SIRS mandates immediate surgical intervention, not observation 1

Option D (Forced manual reduction) is contraindicated because:

• Attempting reduction of a potentially strangulated hernia risks reducing necrotic bowel into the abdomen, causing peritonitis 4
• The presence of fever and extreme leukocytosis suggests tissue necrosis that requires surgical debridement, not reduction 1

Surgical Approach and Timing

Immediate open surgical exploration is mandatory because:

• Surgery should be performed within 6 hours of symptom onset to minimize bowel resection and mortality 1
• Open approach is required when bowel resection is anticipated or strangulation is confirmed 1
• The extreme WBC elevation raises concern for Fournier's gangrene, which requires surgical intervention as soon as possible with removal of all necrotic tissue 2

Intraoperative Considerations

During surgical exploration, the surgeon must:

• Assess bowel viability and perform resection if necrotic bowel is identified 1
• Consider mesh placement based on surgical field contamination: synthetic mesh can be used in clean or clean-contaminated fields (CDC Class I-II), but biological mesh or delayed repair may be needed if gross contamination is present 5, 1
• Obtain tissue cultures if Fournier's gangrene is identified, and initiate broad-spectrum antibiotics covering gram-positive, gram-negative, aerobic and anaerobic bacteria with anti-MRSA coverage 2
• Plan for repeat surgical revisions if extensive tissue necrosis is found, as serial debridements may be necessary 2

Common Pitfall to Avoid

Never delay surgical intervention in suspected strangulated hernia—the elapsed time from symptom onset to surgery is the single most important prognostic factor (P<0.005), and delayed diagnosis beyond 24 hours is associated with significantly higher mortality rates 5, 1